Burkitt Lymphoma and Plasmablastic Lymphoma

Differences and similaritiesLorenzo Leoncini

University of SienaItaly

• Endemic BL was the first human tumor for which a viral association has been shown

• The first human tumor for which a chromosomal translocation resulting in the activation of an oncogene was identified

• The first tumor to be successfully treated with chemotherapy alone

AFTER

A single molecular and morphological entity with variations in clinical presentation

Endemic, Sporadic, Immunodeficiency

Endemic BL

• Equatorial Africa• Correlation with incidence & climatic factors, Malaria• High incidence among children• Peak Incidence, 4-7 yrs, Males : Females 2:1• Sites: Extranodal sites 20% involve jaws,

other facial bones Leukemia rare

• EBV 100%

Sporadic BL• Tumor histologically identical to BL identified in other parts

of the world, including US and Europe

• Approximately 30% of childhood lymphomas

• 1-2% of all lymphomas

• Median age - approximately 12 yrs.

• Male: Female ratio - 2-3:1

• Jaw tumors less frequent

• GI most common site of involvement

• Ovaries, Breast (at pregnancy, puberty)

• EBV 20-30%

Immunodeficiency Associated BL

• Presents early in the course of HIV, often as the initial manifestation of infection

• CD4 counts generally normal

Common Features of BL variants

Immunophenotype

Morphology

Myc rearrangementMost proliferative of all human tumors100% of cells in cycle, 27% in S phase

Bcl6 Bcl2CD 10

c-MYC

The MYC transcription factor is pathologically activated in many human malignancies:

Genomic aberrationsChromosomal amplifications

Mutual translocations

Hummel M et al. Molecular Mechanisms in Malignant Lymphomas Network Project of the Deutsche Krebshilfe A biologic definition of Burkitt's lymphoma from transcriptional and genomic profiling. N Engl J Med. 2006 Jun 8;354(23):2419-30.

Piccaluga et al. Blood 2011

Piccaluga et al. Blood 2011

BCR signaling pathway

Relatore

Note di presentazione

weather coincidental infections with additional pathogens increase the risk of EBV positive BL in endemic areas remain to be addressed no definitive data is available for the mutations affecting the TCF3 and the ID3 in endemic (eBL

Schmitz R et al. Nature 2012

This rate of mutations is significantlylower than that reported in sBL (70%).

This finding seems to be consistent with thehypothesis that an activation of B-cellreceptor through an extrinsic antigen-drivensignaling could be present in eBL and maydepend on the presence of multiplepathogens

Co-factors in endemic Burkitt’s Lymphoma

EBV

• Burkitt’s Lymphoma is endemic in region with mean minimum temperatures> 15,5°C and annual rainfall

• eBL common in wet areas. The altitude gradient is in effect a temperature gradient.

• Shifting foci, space-time case-clusters and seasonality observed in eBL

Lymphoma Belt of Africa

Malaria and EBV are ubiquitous within the lymphoma belt of Africa

Then Burkitt’s Lymphoma should be commoner than it is. Are there other co-factor candidates?

EBV can interact with malaria, planttumour promoters and arboviruses

• EBV and malaria boost eBL incidence by x 100-150 in LB

• VCA levels increased pre eBL up to 6 yrs before. Only antibody which changes before tumour develops

• EBV activated by plant phorbol esters. Interactions include eBL 8:14 t in 1% of cells in Lymphoblastoid Cell Lines

• EBNA1 found to increase HCV replication

BL DLBCL

Terapia specifica

HD-MTX e ARA-C

% Cura

70-90%

Terapia specifica

CHOP-R

% Cura

~50%

Non nota terapia efficaceScarsa efficacia

CHOP-R

% Cura

0%

B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Burkitt lymphoma

(2008) 4th Edition

CLINICA:

Adulti

Sede: prevalentemente extranodale SNC

Presentazione leucemica

IMMUNO :CD20+, CD79a+ CD10+, Bcl6+

Bcl2-, MUM1- /debole

Bcl2 -/+ o +

Mib1 50-100%

GENETICA

MYC R 35-50%

No MYC-IGH

BCL2 R 15% spesso con MYC (double hit)

Raro BCL6 R con o senza MYC e BCL2

Cariotipo complesso

LINFOMA A CELLULE B INCLASSIFICABILE INTERMEDIO TRA DLBCL e BL

Bcl2

Mib1

Categoria eterogenea da non considerare come una distinta entità patologica.Categoria « pratica » per classificare i casi che non soddisfano i criteri diagnostici per BL e DLBCL

CD20-positive aggressive B-cell lymphoma after exclusion of lymphoblastic lymphoma

Phase 1 scoring

Morphology (0-3)BCL2 (2 - neg.; 1- wk.)CD10 (1, if pos.)

Cumulative score:5-6 – BL3-4 – BL not excluded<3 – not BL

Phase 2 scoring

Morphology (0-3)BCL2 (2 - neg.; 1- wk.)CD10 (1, if pos.)Ki-67 (2 - >95%; 1 - 90-95%)CD38 (1, if pos.)CD44 (1, if neg.)

Cumulative score:>8 – BL6-7 – BL not excluded<6 – not BL

Phase 3 scoring

Morphology (0-3)BCL2 (2 - neg.; 1- wk.) CD10 (1, if pos.)Ki-67 (2 - >95%; 1 - 90-95%) CD38 (1, if pos.)CD44 (1, if neg.)FISH (2, if MYC-Ig pos. & BCL2/BCL6 neg.)

Cumulative score:>8 – BL6-7 – BL not excluded*

* Benefit from karyotype, CGH, gene expression and assessment of the impact of each of the parameters

Fase 181,7%

Fase 210,7%

Fase 32,8%

95,2%

RESULTS

RESULTS

N. positive

(%)

N. negative

(%)

Intensity of

staining

Pattern of expression

BL 45(96%)

2 (4%) strong single or multiple droplets into thecytoplasm, clustering around theouter nuclear membrane

notBL

3 (9%) 30 (91%) weak single, very small droplets into thecytoplasm

…close attention to the cellular details helps further distinguish these related but distinct neoplasms… composed of blasts with a light chromatin and one to a few prominent nucleoli and not containing proplasma cells and mature plasma cells …tipical of plasmacytomas.

PBL show a morphological spectrum varying from a diffuse and cohesive proliferation of cells resembling immunoblasts, cells with more obvious plasmacytic

differentiation, which may resemble cases of plasmablastic plasma cells myeloma

PLASMABLASTIC LYMPHOMAHarald Stein, Nancy L. Harris, Elias Campo

Caratteristiche ClinicheINCIDENZA: <1% NHL

ETÀ(media,range): 40aa (7-60) HIV+

60aa (1-80) HIV-

SESSO M/F: 7:1

SEDE: Cavità orale (90% in HIV+)

Extra-orale: Seno Mascellare,Nasofaringe, Tratto Gastrointestinale,Orbita,Cute, Polmone, Tessuti Molli,Osso,Mediastino, Vulva

Nodale: raro (HIV-)

EZIOLOGIA: EBV 60-75% (Cavità orale ~100%)

HIV 80%

HHV8 assente

Immunosoppressione post-trapianto,iatrogena

PROGNOSI: aggressivo, sopravvivenza 1aa dalla diagnosi

Linfoma Plasmablastico secondario

Tumours with features of PBL may occur in patients with prior plasma cell myeloma. Such cases should be considered plasmablastic tranformation of myeloma and distinguishedfrom primary plasmablastic lymphoma.

IstologiaPattern di crescita diffusoFrequente starry skyNumerose mitosi e corpi apoptoticiAree di necrosi confluenti comuni

Proliferazione monotona coesiva di grandi cellule ad aspetto blastico Immunoblasti: grande nucleolo centrale con scarso o assente citoplasma Differenziazione Plasmablastica: nuclei eccentrici, marcato citoplasma basolfiloPresenti elementi Binucleati o MultinucleatiCorpi di Russell e Dutcher assenti

Differenziazione Plasmacitica

Proliferazione polimorfa con cellule di medie e piccole dimensioni con nucleo eccentrico, nucleolo relativamente piccolo,citoplasma abbondante

CD20,PAX5 -

CD79a +/-

Ig citoplasmatiche +

CD38, CD138, MUM-1 +

PRMD1/BLIMP1, XBP1 +

CD45 -/+

CD30, EMA +/-

CD10 +/-CD56 -/+HHV8 -EBV +

EMA

CD138

CD20

Ig

CD45MUM1

Immunofenotipo

Blimp-1

OverlapClinico

MorfologicoImmunofenotipico

LINFOMA PLASMABLASTICO

diagnosi differenziale

DLBCL NosDLBCL Variante ImmunoblasticaLinfoma di Burkitt

PEL

Linfoma Plasmablastico in MCD

Linfoma a Grandi Cellule B ALK+

Mieloma Multiplo PlasmablasticoPlasmacitoma Plasmablastico

Sarcoma MieloideCarcinoma indifferenziatoMelanoma

HHV8

ALK t(2;17) clatrina -ALK

Markers non linfoidi

CD20+ CD20-

Paraproteine sericheBence Jones urinarieBOM positiva alla diagnosiLesioni osteolitiche

Presenza di plasmacellule neoplastiche atipiche e/o mature

EBER-Ki67 più bassoCD56+

Burkitt Lymphomaand Plasmablastic Lymphoma

Two separate entities but with manysimilarities

Extranodal localizationMorphology

Proliferation rateGenetic abnormalities

HIV settingEBV Latency Program

CD10CD20

CD 38 CD 138

Mib-1: 95-100%

t(8;14)(q24;q32) IG/MYC

MYC

BREAK-APART PROBESt(8;14)

c-myc

Why lymphomas in imunocompromised patients show do not show Latency III?

Lymphomas in immunocompromised patients

EBER LMP 1

Latency I

II

Activated B cell

GC

T cell Response

I

III

III

III

EBV Naïve B cell

EBV+ Memory B cell

IIISHM

No SHM

Burkitt cell counterpart?

I = EBNA-1; II = EBNA-1, LMP1/2; III = All EBNAs

Translocation?

Infection

RAG

AID

No T cell Response

Plasmablastic cell counterpart?

Cocco et al. Am J Pathol 2008

The strategy of the virus is to persist in a healthy carrier

• T-cell immunity is believed to play a critical role in the control of EBV infection–Acute infection – T- and NK-cell

LPD–Reactivation memory B-cells – B-

cell-LPD• Oncogenic effect of EBV products

in association with additional genetic, microenviromental and environmental factors

Only expression of EBNA1 (No LMP1, no EBNA2)

Latency I

• Active interplay between virus and hostinvolving miRNAs

• Virus-mediated miRNA dysregulation may beinvolved in several malignancies

Cullen BR, Nature, 2009

MODELS OF miRNA-MEDIATED HOST-VIRUS INTERACTIONS

• Viral transcripts targeting hostmiRNAsMechanism of modulation of host miRNAexpression by viral transcripts

• Viral miRNAs targeting host transcriptsRegulatory role of virus-encoded miRNAson cellular transcriptEBV — host transcripts (associated withapoptosis and tumor suppression)

8/470 hsa-miRNA (3 up, 5 down)

13/44 viRNA (BARTs)

Human and viral miRNA profiling in EBV positive versus EBV negative BLs

miR-192

miR-127

EBV

Antigens

Growth program Latency III

Latency I

Default program Latency II

MYC translocation

EBNA1+AID+miR-127

Latency 0

IgM+ memory B cells

IgG+ memory B cells

Plasma cells

T helper cells

FDC

Apoptosis

High affinity

Low affinity

Naive B cells

EBNA1+AID+miR-??high

Plasmablastic lymphoma

Burkitt lymphoma

Latency I

Proliferation and SHM

Selection

PB ebv+PB ebv-

PC ebv+PC ebv-

12 miRNA cellulari

39 miRNA virali

BL ebv-

PB ebv-PB ebv+

BL ebv+

17 miRNA cellulari

36 miRNA virali

BL ebv+PB ebv+

PB ebv-

ebv-miR-BART- 18-5pebv-miR-BART- 19-5p

hsa-miR-148-3p hsa-miR-148-5phsa-miR-192-5phsa-miR-1304-3p

BL ebv-

BL ebv+

PB

ebv-miR-BART- 18pebv-miR-BART- 19 p

hsa-miR-148a 3p hsa-miR-148a 5phsa-miR-192 5phsa-miR-1304 3p

56aa

M/F: 50%

Extraorale

EBV+ (92%)

HIV- (100%)

46aaM Cavo orale

Seno mascellare

EBV+ (100%)HIV+ (70%)

Secondario a MielomaCD56

IL6TaT

DNMT

TaTProliferazione

Differenziamento

BHLFE41

BRWD1

IL-6

CXCL13

PTRJ

Proliferazione cellulare

Migrazione cellulare

Risposta immunitaria

miR-148a-3p

miR-148a-5p

ApoptosiDifferenziamento

CCNT2GDF11

GDF11 ACVR2B

MAPK6MAP3K

BCL2

PTRJ

MDX1

BRWD1

Regolazione espressione genica

METILAZIONE

DNMT1 DNMT3b

Metabolismo lipidico

FAR2

miR-1304-3pmiR-192-5p

PDP2

PicTar

IL-6

• PBL e BL sono due distinte entita con molte analogie

• miRNA profiling distingue nettamente i PBL dai PC, dato non cosi evidente con i BL

• PBL è una categoria eterogenea che riflette lo stato immunitario del paziente

•I casi HIV + presentano una più marcata differenziazione plasmacitica

• L’ interazione HIV miRNA gioca sicuramente un ruolo importante nella linfomagenesi nelle forme HIV correlate

CONCLUSIONI

University of Siena, Italy

Maria Raffaella AmbrosioCristiana Bellan Giulia De FalcoSara GazaneoStefano LazziLucia Mundo

Polo d'Innovazione di Genomica Genetica e BiologiaPerugia, Italy

G A Z I ER

EBV miRNA BART 18-5p

BCLAF1 Apoptosi

CDKN1C Ciclo Cellulare

TP53INP1 P53 pathway

SOCS3JAK-STAT pathway

PTENAKT-PI3K pathway